Provider Demographics
NPI:1003059379
Name:BLONDET TEIXEIRA, JUAN JOSE (MD)
Entity type:Individual
Prefix:
First Name:JUAN JOSE
Middle Name:
Last Name:BLONDET TEIXEIRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JUAN JOSE
Other - Middle Name:
Other - Last Name:BLONDET
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:280 SMITH AVE N
Practice Address - Street 2:SUITE 700
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2424
Practice Address - Country:US
Practice Address - Phone:651-241-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58898208600000X
CAA129415208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400226956Medicare PIN